Prior Authorization Lookup Tool

Prior Authorization (PA) is the review for medical necessity of healthcare services, medical equipment, and supplies. It is required for outpatient services, out-of-network providers, and planned hospital admissions. Please verify member eligibility and benefit coverage prior to rendering services.

This tool does not include an exhaustive listing of non-covered services (e.g., experimental procedures, cosmetic surgery); please refer to the Texas Medicaid Provider and Procedures Manual (TMPPM) or your provider manual for coverage/limitations.

Some healthcare services that usually would not be covered under Texas Medicaid could be considered under the Comprehensive Care Program (CCP) for eligible clients from birth through 20 years of age with a prior authorization.

Behavioral Health (BH) Services: Carelon Behavioral Health manages BH prior authorizations for PCHP. To obtain authorization for BH services, please contact Carelon by phone at 1-800-945-4644 or by fax at 781-994-7111. For more information, please visit  https://www.carelonbehavioralhealth.com/providers/forms-and-guides/tx.

NOTE: Behavioral Health benefits are not covered for members eligible under the CHIP Perinate program.

Pharmacy Services: PCHP contracts with Navitus Health Solutions to provide pharmacy benefits. To contact Navitus, please call 1-877-908-6023 or visit www.navitus.com.

Vision Services: Avesis Third Party Administrators, Inc. manages PCHP's eye care benefits. To obtain authorization for vision services, please call Avesis at 1-866-563-3591 or visit https://myavesis.com/.

Please be advised that some codes may be available under multiple benefits (such as medical, pharmacy, behavioral health, and vision). All PA requests for medical services are submitted through PCHP. For services delivered under vision, pharmacy, or behavioral health benefits, further instruction will be provided by PCHP's vision, pharmacy, or behavioral health delegates.

Please note:

• This lookup tool is for outpatient services only.
• Prior Authorization is required for all service request(s) over benefit limitations within the TMPPM.
• Emergency Care: A PA request is not required.
• Durable Medical Equipment (DME): A PA request is required for DME and supplies with a total amount greater than $5,000.
• Transplant services require prior authorization.

The code descriptions used in this tool are taken from the American Medical Association (AMA) short description language and do not supersede any other Texas Medicaid program benefit, claim processing guidance outlined in the TMPPM, fee schedules, or provider contracts.